The relative readmission rates comparing the control group with the
intervention group are 1.96 (95% confidence interval [CI],
1.31-2.92) for the crude rate and 2.03 (95% CI, 1.34-3.08) for the
adjusted rate. The survival curve distance is P<.001
(calculated with the log-rank test).

Author Affiliations: School of Nursing (Dr Naylor and Mss Campbell and Jacobsen), The Wharton School (Dr Pauly), and School of Medicine (Dr Schwartz), University of Pennsylvania, Philadelphia; School of Nursing, Case Western Reserve University, Cleveland, Ohio (Dr Brooten); and Division of Nursing, New York University, New York, NY (Dr Mezey).

Context Comprehensive discharge planning by advanced practice
nurses has demonstrated short-term reductions in readmissions of
elderly patients, but the benefits of more intensive follow-up of
hospitalized elders at risk for poor outcomes after discharge has not
been studied.

Objective To examine the effectiveness of an advanced
practice nurse–centered discharge planning and home follow-up
intervention for elders at risk for hospital readmissions.

Participants Eligible patients were 65 years or older,
hospitalized between August 1992 and March 1996, and had 1 of several
medical and surgical reasons for admission.

Intervention Intervention group patients received a comprehensive
discharge planning and home follow-up protocol designed specifically
for elders at risk for poor outcomes after discharge and implemented by
advanced practice nurses.

Main Outcome Measures Readmissions, time to first readmission,
acute care visits after discharge, costs, functional status,
depression, and patient satisfaction.

Results A total of 363 patients (186 in the control group and 177
in the intervention group) were enrolled in the study; 70% of
intervention and 74% of control subjects completed the trial. Mean age
of sample was 75 years; 50% were men and 45% were black. By week 24
after the index hospital discharge, control group patients were more
likely than intervention group patients to be readmitted at least once
(37.1% vs 20.3%; P<.001). Fewer intervention group
patients had multiple readmissions (6.2% vs 14.5%;P = .01) and the intervention group had fewer hospital days per
patient (1.53 vs 4.09 days; P<.001). Time to first
readmission was increased in the intervention group
(P<.001). At 24 weeks after discharge, total Medicare
reimbursements for health services were about $1.2 million in the
control group vs about $0.6 million in the intervention group
(P<.001). There were no significant group differences in
postdischarge acute care visits, functional status, depression, or
patient satisfaction.

Conclusions An advanced practice nurse–centered discharge
planning and home care intervention for at-risk hospitalized elders
reduced readmissions, lengthened the time between discharge and
readmission, and decreased the costs of providing health care. Thus,
the intervention demonstrated great potential in promoting positive
outcomes for hospitalized elders at high risk for rehospitalization
while reducing costs.

The continued growth of diagnosis related groups (DRGs) and
capitated reimbursement
for inpatient care have increased pressures on hospitals to reduce
length of stay. Consequently, elders with complex health needs are
being discharged from hospitals earlier.1- 3 Home health
services and families have served as safety nets for many of these
patients. However, the rapid and dramatic growth of home health care
has recently resulted in decreased access to services.4- 6
Potential consequences for elders with serious health problems include
increased risk for preventable hospital readmissions and nursing home
placement.7- 11

Recent studies have evaluated innovative interventions to facilitate
the transition of older adults from hospital to home.12- 17
Most of these efforts focused on elders hospitalized with specific
health problems, such as congestive heart failure
(CHF).12- 14,17 A randomized trial17 that we
completed in 1992 demonstrated short-term reductions in readmissions
and decreased costs of care for
hospitalized elders with medical cardiac conditions
managed according to a comprehensive discharge planning protocol
implemented by advanced practice nurses (APNs). Findings suggested that
elders at risk for poor outcomes after discharge might benefit from
more intensive home follow-up.

The objective of this randomized clinical trial was to examine
the effectiveness of an APN-centered comprehensive discharge planning
and home follow-up protocol for elders hospitalized with 1 of several
common medical and surgical reasons for admission. Based on our earlier
research, we hypothesized that this intervention would improve patient
health outcomes and reduce service utilization and health care costs
compared with usual hospital and home care.

METHODS

Study Sample

The study was conducted at the Hospital of the University of
Pennsylvania and the Presbyterian Medical Center of the University of
Pennsylvania Health System and was approved by the institutional review
boards at both institutions. All subjects screened for study
participation were age 65 years or older and were admitted from their
homes to either hospital between August 1992 and March 1996 with 1 of
the following diagnoses: CHF, angina, myocardial infarction,
respiratory tract infection, coronary artery bypass graft, cardiac
valve replacement, major small and large bowel procedure, and
orthopedic procedures of lower extremities. These diagnoses were among
the top 10 reasons for Medicare beneficiary hospitalization in
1992.18 The DRGs were assigned at hospital admission and
validated at discharge.

Eligible patients had to speak English, be alert and oriented when
admitted, be able to be contacted by telephone after discharge, and
reside in the geographic service area. Patients also had to meet at
least 1 of the following criteria associated with poor postdischarge
outcomes in our earlier study17: age 80 years or older; inadequate support system; multiple, active, chronic health problems;
history of depression; moderate-to-severe functional impairment;
multiple hospitalizations during prior 6 months; hospitalization in the
past 30 days; fair or poor self-rating of health; or history of
nonadherence to the therapeutic regimen.

Of the 1296 patients screened, 28% were enrolled, a percentage
consistent with randomized clinical trials involving similar
populations.13,19 The 72% not enrolled comprised those
discharged before screening (29%) and refusals (43%) (Figure 1). Enrollees and refusals were similar in
race (P = .99) and sex (P=.25). Mean
ages differed by 2 years (75.4 years for enrollees vs 77.3 years for
refusals, P<.001).

Study Design

Patients were enrolled in the study within 48 hours of hospital
admission by research assistants (RAs) blinded to study groups and
hypotheses. After screening patients for eligibility and obtaining
informed consent, RAs notified the project manager who assigned
patients to study groups using a computer-generated algorithm. The
project manager contacted APNs if patients were assigned to the
intervention group. Baseline data on both groups (ie, sociodemographic
and health status characteristics, functional status, and depression)
were collected at enrollment by RAs using standardized instruments
(Table 1).

Control Group. Control group patients received discharge planning that was routine for
adult patients at study hospitals. If referred, control group patients
received standard home care consistent with Medicare regulations.

Intervention Group. The intervention extended from hospital admission through 4 weeks after
discharge. The APNs assumed responsibility for discharge planning while
the patient was hospitalized and substituted for the visiting nurse
(VN) during the first 4 weeks after the index hospital discharge. Over
the course of the study, the protocol was implemented by 5 part-time,
master's-prepared, gerontological APNs with a mean of 6.5 years
(range, 2-9 years) postdegree experience in hospital and/or home care
of older adults.

Intervention group patients and their caregivers, if available,
received a standardized comprehensive discharge planning and home
follow-up protocol designed specifically for elders at high risk for
poor postdischarge outcomes. The protocol guided patient assessment and
management and specified a minimum set of APN visits. However, an
important component of the intervention was the ability of the APN, in
collaboration with the patient's physician, to individualize patient
management within the bounds of the protocol.

The protocol was implemented as follows: initial APN visit within 48
hours of hospital admission; APN visits at least every 48 hours during
the index hospitalization; at least 2 home APN visits (1 within 48
hours after discharge, a second 7-10 days after discharge); additional
APN visits based on patients' needs with no limit on number; APN
telephone availability 7 days per week (8 AM to 10
PM on weekdays and 8 AM to noon on weekends); and
at least weekly APN-initiated telephone contact with patients or
caregivers.

Hospital Visits. The APNs used data generated from instruments of
established validity and reliability (Table 1) and
their clinical skills to identify patients' and caregivers' discharge
needs. Assessment focused on nature and severity of health problems;
age-related changes; physical, functional, cognitive, and emotional
health status; and discharge goals. Caregiver assessment also included
social support,20 knowledge and skills,
strain,21 and need for formal support. Based on this
information, APNs collaborated with the patient, physician, caregiver,
and other team members in designing an individualized discharge plan.
The APN implemented the plan through direct clinical care, patient and
caregiver education, validation of learning, and coordination of needed
home services. The APNs attempted to schedule hospital meetings with
caregivers present. Within 24 hours of discharge, physicians wrote
discharge orders and APNs scheduled the initial home visit.

Home Visits, Telephone Availability, and Outreach. The APNs completed physical and environmental assessments and targeted
efforts at increasing patients' and caregivers' ability to manage
unresolved health problems. Based on individual needs, APN
interventions focused on medications, symptom management, diet,
activity, sleep, medical follow-up, and the emotional status of
patients and caregivers. A variety of strategies reinforced teaching
including written instructions and medication schedules. Through home
visits and telephone follow-up, APNs addressed questions or concerns
from patients, caregivers, or health team members; monitored patients'
progress; and collaborated with physicians to make adjustments in
therapies and obtain referrals for needed services.

Discharge Summaries. At completion of the intervention, APNs sent written summaries to
patients, caregivers, physicians, and other providers to whom APNs had
referred patients, detailing the plans, goal progression, and
ongoing concerns.

Outcome Measures

Outcome measures included hospital readmissions related to any cause,
recurrence or exacerbation of the index
hospitalization DRG, comorbid conditions, or new health problems. The
primary intervention efficacy test was defined on the basis of time to
first readmission for any reason. Secondary outcomes were cumulative
days of rehospitalization, mean readmission length of stay, number of
unscheduled acute care visits after discharge, estimated cost of
postindex hospitalization health services, functional status,
depression, and patient satisfaction. Outcome data were collected by
RAs blinded to study groups and hypotheses.

Standardized telephone interviews with patients at 2, 6, 12, and
24 weeks after index hospital discharge identified patients'
readmissions to any hospital and unscheduled acute care visits to
physicians, clinics, and emergency departments. Data on functional
status (measured by the Enforced Social Dependency
Scale),22 depression (assessed using the Center for
Epidemiologic Studies Depression Scale),23 and patient satisfaction (measured by an investigator-developed instrument) were
also collected during these interviews.

Data on the number, timing, reasons, and charges for readmissions,
unscheduled acute care visits, and home visits by VNs or APNs
(intervention group only), allied health professionals, and assistive
personnel were abstracted from patients' records (inpatient,
outpatient, and home care) and bills and recorded on standardized data
collection forms. Reasons for readmissions were validated in writing by
patients' physicians. The RAs categorized the reasons using discharge
diagnoses as index-related (discharge diagnosis same as index
hospitalization); comorbid (discharge diagnosis 1 of comorbid
conditions identified at index hospitalization); or new health problem
(not related to index diagnosis or comorbid condition during index
admission). Estimated resource costs were generated using standardized
Medicare reimbursements. Costs of pharmaceuticals, over-the-counter
drugs, assistive devices, other supplies, and indirect costs (eg,
productivity losses by patients and caregivers) were not included.

Statistical Analysis

For patients who did not complete the entire 24-week postindex
hospitalization study period (death or withdrawal), data collected
between randomization and withdrawal were used in the analyses,
performed according to the intention-to-treat principle, and censored
at time of death or withdrawal.

Baseline data for intervention and control groups were compared
using χ2 tests for categorical variables, t
tests for normally distributed continuous variables, and the Wilcoxon
rank sum test for abnormally distributed variables. Based on a prior
clinical trial,17 we estimated that in
each of the 2 study
groups, 125 patients had to complete the study to detect a 50%
reduction in hospital admission rates (2-sided α, .05 and power,
0.80, based on a control group readmission rate of 0.30).26

Descriptive comparisons between groups used χ2 tests for
the proportions of patients readmitted, t tests or Wilcoxon
rank sum tests for number of readmissions, total days of
hospitalization, mean readmission length of stay, number of acute care
visits, and reimbursements for postdischarge health services.
Multivariate analysis of variance tested for measures of functional
status, depression, and patient satisfaction.

Kaplan-Meier survival curves27 were
used to compare control
and intervention groups to account for unequal follow-up times for the
primary end point of time to first readmission for any reason and the
secondary outcomes of time to first index-related readmission and time
to first readmission or death. Crude testing of the primary hypothesis
that the 2 cumulative readmission-free rate curves were identical was
performed using a log-rank statistic.28 Potentially
confounding variables were adjusted using proportional hazards
regression,29 providing an adjusted hospital readmission
rate ratio (incidence density ratios) along with 95% confidence
intervals (CIs). A final multivariate model included covariates
retaining their bivariate significance (P<.05) along with
intervention group to obtain adjusted significance levels and adjusted
risk estimates with 95% CIs. Variables were removed in a stepwise
manner. Intervention group interactions with significant index
diagnoses were assessed by adding appropriate terms to the model.

Group differences in both charges and actual Medicare reimbursements
for postindex hospitalization health services were examined. The more
conservative reimbursement results are reported. Although
reimbursements are not the same as costs, they are a reasonable proxy
and provide reasonably unbiased estimates of relative differences in
cost between intervention and control groups. The index hospital
reimbursement included the costs of discharge planning services
provided by registered nurses, social workers, and discharge planners.
Since the APN hospital visits in this intervention substituted for
standard discharge planning, no additional costs were assigned to this
phase of the intervention. The cost of APN services after
discharge was estimated by assessing APN intervention–related effort
(from detailed logs) and applying Medicare reimbursement rates. In the
primary analysis, postdischarge APN and VN services were assigned the
same rate since this reflected Medicare's reimbursement during the
study period. Sensitivity analyses were conducted using higher
estimates for APN services (actual APN reimbursement plus 20%),
reflecting their increased skill and training relative to VNs, and
representative annual salary for APNs plus benefits was weighted by
percentage of effort attributable to the intervention.

RESULTS

Study Patients

A total of 363 patients were enrolled in the study (Table 1). The 2
study groups were similar in all sociodemographic and baseline health
characteristics, including index hospitalization DRG, type of
admission, and length of stay. Mean age of the entire sample was 75
years, 50% were men, and 45% were black.

The attrition rate from the intervention group (including deaths) was
30% (53/177) compared with 26% (48/186) for the control group
(P=.26). Of the 363
enrolled patients, 22 (6%) died by 24 weeks
after discharge, with 11 deaths in each of the 2 study groups (Figure
1). Most of the deaths occurred during the index hospitalization or in
the first 6 weeks after discharge (4% control, 5% intervention). An
additional 4% in each of the study groups withdrew because of
inability to complete follow-up interviews (changes in health status
such as stroke or cognitive decline). The remaining withdrawals (16%
control, 20% intervention; P=.64) occurred
because patients changed their minds about participating (13% control,
18% intervention; P=.28); moved away (1%
control, 1% intervention); or were discharged to a nursing home (2%
control, 1% intervention). Intervention group withdrawals were
slightly higher because a few patients in this group decided, after
enrolling, to maintain existing VN relationships and services.

Study follow-up did not differ significantly between control and
intervention groups (18.1 weeks vs 19.1 weeks;
P=.41). The 28% attrition rate was consistent
with rates reported in other randomized clinical trials with a similar
patient population.17,19,30 The 262 patients who completed
the study and the 101 persons in the attrition group did not
significantly differ in sociodemographic variables and severity of
illness measures (eg, number of comorbid conditions).

Readmissions

Control group patients were more likely than intervention
group patients to be readmitted at least once (Table
2; 37.1% vs 20.3%; P<.001;
relative risk, 1.8; 95% CI, 1.3-2.6). The 16.8% absolute reduction in
hospital readmissions at 24 weeks represented a 45% relative reduction
in control group readmission rate. More control group patients had
multiple readmissions during the 24-week period than intervention group
patients (14.5% vs 6.2%; P=.01; relative
risk, 2.3; 95% CI, 1.2-4.6).

The intervention resulted in fewer total hospital readmissions at 24
weeks after index hospitalization discharge (107 control vs 49
intervention; rank sum test, P<.001). The reduction in
readmissions was significant during both the first 6 weeks after
discharge (P<.001) and the 6-week to 24-week period
(P=.02).

Of the 156 readmissions, 60.3% were related to the index
hospitalization, 22.4% to comorbid conditions, and 17.3% to new
health problems. There were fewer readmissions related to the index
hospitalization in the intervention group compared with the control
group (30 vs 64; P=.005). There were trends
toward reduced intervention group readmissions due to comorbid
conditions (10 vs 25; P=.06) and new health
problems (9 vs 18; P=.10).

At 24 weeks, control group patients experienced 760 days of
hospitalization, compared with 270 days in the intervention group
(P<.001). Hospital days per patient were higher in the
control group compared with the intervention group (4.09 vs 1.53; rank
sum test, P<.001 [with or without adjustment for follow-up
time]). The mean length of stay for readmitted patients in the control
group (n=69) was higher than the intervention group
(n=36), (11.0±10.6 days vs
7.5±4.8 days; P<.001).

Time to first readmission for any reason was increased in
the intervention group (log-rank
χ21=11.1, P<.001)
(Figure 2). Twenty-five percent of
control patients were readmitted within 48 days after index hospital
discharge (95% CI, 34-63 days), whereas 25% of intervention patients
were readmitted within 133 days (lower 95% confidence limit, 78 days;
upper 95% confidence limit, not estimable). The effect of the
intervention on time to first readmission for any reason remained
significant (P<.001, Table
3) after adjusting for simultaneously
significant variables including self-reported health status, number of
hospitalizations in the previous 6 months, living arrangements, and
diagnosis of CHF. The time to index diagnosis-related readmissions
similarly was increased in the intervention group (log-rank
χ21=4.97,
P=.03).

Statistical evidence was weak that the relative efficacy differed
between
patients with and without CHF
(χ21=2.47,
P=.11). The crude rates for any readmission
per year among control and intervention patients without a CHF
diagnosis were 1.17 (41 events/35.2 years) and 0.42 (16 events/38
years), respectively, for a crude relative rate of 2.8. Among CHF
patients, the crude control and intervention group admission rates per
year were 1.93 (25 events/13 years) and 1.48 (19 events/12.8 years),
respectively, for a crude relative ratio of 1.30. In clinical terms,
however, the intervention's relative efficacy was significantly larger
for patients without CHF compared with patients with CHF (rate ratio,
1.6 vs 2.7).

Relative efficacy did not depend on study site for time to any
first admission (P=.82). When a secondary end
point defining deaths as an event rather than being censored was
examined, time until first readmission for any reason remained
increased in the intervention group (rate ratio, 1.6; 95% CI, 1.1-2.3;
P=.01).

Other Patient and Health
Services Outcomes

Intervention and control groups were similar in mean
functional status (P=.33), depression scores
(P=.20), and patient satisfaction
(P=.92). At 24 weeks, mean functional status
scores in both groups were slightly improved over baseline (21.5 to
19.2) as were mean depression scores (10.7 to 6.6). Mean patient
satisfaction scores showed little change over time; both groups
remained highly satisfied with care.

At 24 weeks after discharge, the control and intervention
groups did not significantly differ in the mean number of unscheduled
acute care visits to physicians or emergency departments, or home
visits by VNs or APNs, allied health professionals, or home health
aides (Table 4). The pattern of home
visits by nurses immediately after index hospital discharge differed
between study groups. Only 44% of the control group received at least
1 home visit by VNs during the first 2 weeks after discharge.
Consistent with the study protocol, all of the intervention group
received at least 1 APN visit. Of the 69 control patients
rehospitalized at least once, 51% received VN visits during the
immediate postdischarge period.

Economic Impact

At 24 weeks, total and per-patient imputed reimbursements for postindex
acute health services in the control group were approximately twice as
much as that of the intervention group ($1,238,928 vs
$642,595 [P<.001] and $6661 vs $3630
[P<.001]; Table 5). Intervention group cost savings were driven by the control group's
substantially greater total DRG reimbursements for all hospital
readmissions at 24 weeks after discharge ($1,024,218 vs
$427,217; P<.001). Substitution of charges, adjusted
charges, and weighted APN average annual salary and benefits for
reimbursements as measures of resource use further increased the
estimated differences between groups. Total reimbursements for other
postdischarge acute care visits were not significantly different
between study groups (Table 4; P=.72).

COMMENT

This study demonstrated that a comprehensive discharge planning and
home follow-up intervention designed specifically for elders at high
risk for poor posthospital discharge outcomes and implemented by
gerontological APNs reduced hospital readmissions, lengthened the time
to first readmission, and decreased cost of care. Improved patient
outcomes and health care savings have also been demonstrated when a
similar approach to care was tested with women with high-risk
pregnancies and low-birth-weight infants.31- 33

By 24 weeks after the index hospital discharge, 37% of the control
group had been rehospitalized compared with 20%
of the intervention group. Although nonrandomized
studies12,34,35 have demonstrated greater reductions in
rehospitalization rates for adult cardiac patients, only 1 randomized
clinical trial, limited to patients with congestive heart failure,
demonstrated a similar absolute readmission rate
reduction.13 In contrast to this study that included
rehospitalizations to any hospital, other studies have examined only
readmissions to study hospitals34 or did not specify if
readmissions to hospitals other than study hospitals were
included.13,35

Study findings are especially important given the current
attention to new models of patient care management. In contrast to the
typical disease management model that focuses on all patients
hospitalized with a specific primary condition, such as heart failure,
this intervention targeted elders hospitalized with common medical and
surgical conditions. We believe that the focus of the clinical
intervention on the combined effects of primary health problems,
comorbid conditions, and other health and social issues common in this
patient population, rather than on the management of a single disease,
was a major factor in its success.

Other factors may have contributed to these observed outcomes. The
target study population, elders at high risk for poor outcomes after
hospital discharge, was not limited to those who met current Medicare
home-care eligibility requirements. Approximately one third of control
patients who did not receive a visit from a VN immediately after the
index discharge were rehospitalized. The factors that influence health
professionals' decision making regarding which patients are referred
for home care is an important area for further study. Home visits
alone, however, do not explain the differences in group outcomes
demonstrated in this study. One in 2 control patients visited by VNs
immediately after the index hospital discharge were rehospitalized
compared with 1 in 5 intervention patients visited by APNs.

While the protocol tested in this study was derived from current
research, the framework that guided APNs' decision making was
individualized care. In contrast to most VNs who are
bachelor's-prepared generalists, the APNs who implemented this
protocol were master's-prepared specialists in gerontological nursing.
This intervention benefited from APNs' clinical acumen as well as
their expertise in communicating, collaborating, and coordinating care
with physicians and other health care professionals. For example, a
preliminary analysis of APNs' case studies suggests that joint
clinical decision making with physicians resulted in timelier
interventions in the home and prevented negative outcomes.

Unlike home care nurses, whose visit
pattern is constrained by reimbursement and other
barriers, APNs used their judgment to define the frequency, intensity,
and focus of contacts needed to meet patient and caregiver needs.
Consequently, the time and focus of services provided by the APNs
varied.

Functional status was not improved with this intervention, a finding
consistent with published data from other discharge planning and home
care studies in recent years.30,36 Reductions in
rehospitalizations and cost in the absence of differences in functional
status may indicate that the APN-based intervention achieved its
benefit by enhancing the capacity of high-risk elders to better cope
with their multiple medical problems and disabilities.37
Mean scores at all data collection points revealed little evidence of
depressive symptoms in this study sample.24 The skewed
distribution of patient satisfaction scores suggests the need for more
sensitive items.

At 6 months, the intervention generated estimated savings in Medicare
reimbursements for all postindex hospital discharge services of almost
$600,000 for the 177 intervention group beneficiaries, a mean
per-patient savings of approximately $3000. Thus, the intervention was
dominant from an economic perspective—improved outcomes were achieved
at reduced cost. Virtually all of the savings resulted from
reductions in rehospitalizations, with use of nonhospital postdischarge
health services similar in intervention and control groups. When
extrapolated to the number of older adults hospitalized each year with
similar conditions, the potential patient benefits and savings to the
Medicare system resulting from this intervention are substantial.

In conclusion, an APN-centered discharge planning and home care
intervention for at-risk, hospitalized elders reduced readmissions,
lengthened the time between discharge and readmission, and decreased
the costs of providing heath care. This intervention has great
potential in promoting positive outcomes for this challenging group of
elders while reducing costs.